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Clinical Supervision Case Presentation Outline Demographics … - clinical supervision case presentation format


Clinical Supervision Case Presentation Outline Demographics …-clinical supervision case presentation format

Clinical Supervision
Case Presentation Outline
Demographics-Age, Gender of identified consumer
Presenting concern:
When you arrived on site/responded via phone what did you do?
Who did you talk to?
What did you learn as you began your assessment of the individual in crisis?
What were the risk factors and warning signs present:
Suicide attempt/"gesture"/threat and history of past suicidal behavior
Mental illness (confirmed or apparent) and history of past illness/treatment
AODA - alcohol or drugs currently on board and/or past history of substance abuse
Means to carry out threat, and intent to carry out plans
What has changed recently - current stressors
What were the person's strengths, protective factors and level of cooperation?
Family/friends/others
Individual and others (LE, therapist, family, human services)
supports
What did you do for an outcome
Was it least restrictive
When response planning what was the plan -what considerations did you take into account
Questions/concerns/comments regarding this case
Updated 5.2.16
Clinical Consultation
Case Presentation Outline
When to call for clinical consultation (715-309-4247):
Upon employment with NWCGC/NWC it is expected that the crisis worker will utilize the clinical line for a
minimum of the first five calls prior to making a determination of need.
If you encounter a situation that is more unusual, complex or higher risk and you would like to problem solve,
seek guidance, or achieve concurrence on your plan.
When your concerns/questions are related to clinical assessment, diagnosis, risk levels, or safety planning.
If there is irresolvable disagreement between crisis staff and collateral parties that is related to the assessment of
the crisis.
What to do if you cannot reach the clinical consultant:
Leave a message (numbers may come up blocked). Clinical should respond within 5 minutes. If no response try
one more time
If still no response:
o Mobile calls NWC at 888-552-6642. Call center staff looks at the clinical consultation calendar and
determine who is on call for the clinical consultation line.
o Telephone worker provides the on call person's number listed on the clinical consultation calendar and
directs person to contact person via that number (if no answer-leave voice mail and try again). If still no
answer, call back to call center.
o Call center will provide 2 other clinical numbers noted in no order
Case presentation guideline
Who are you (full name and county/call center), which county is this regarding, and your current location (if
mobile)
Primary reason for calling today (this allows the consult to know what you are needing for assistance be it
directive, teaching, or support) -some examples are:
o new staff-first five
o the county directive requires me to connect with you (see specific counties regarding this)
Winnebago Hospitalization Approval
Crisis Bed Approval
o confused about a diagnosis/mental health disorder
o logistical/legal concerns
o experiencing conflict from/with another professional
o struggling with an outcome or response plan
Who you are working with(age/gender)
How were you notified to respond/assist to a crisis? who contacted you? what did they say?
What is the primary concern today?
When you arrived on site/responded via phone what did you do? who did you talk to?
What were the risk factors/warning signs?
o Suicide attempt/"gesture"/threat and history of past suicidal behavior
o Mental illness (confirmed or apparent) and history of past illness/treatment
o AODA - alcohol or drugs currently on board and/or past history of substance abuse
o Means to carry out threat, and intent to carry out plans
o What has changed recently - current stressors
What were the person's strengths, protective factors and level of cooperation?
o Family/friends/others available to provide a supervised community placement.
Updated 5.2.16
o Individual and others (LE, therapist, family, human services) agree that he/she will be safe, and if things
change there is a plan to respond as necessary.
o Protective factors are present as indicated on the crisis assessment.
o Individual's ability to cooperate with a community safety plan?
What is the past experience? Has the individual responded well to a community safety plan in the past?
What was your impression? What you are thinking of doing, what were your tiers of restriction reviewed?
Example of what this might look like:
Hey, this is [YOUR NAME] from the call center. I'm contacting you about a 25-year-old female out of Eau Claire
County. The reason I'm calling is because I'm having a difficult time coming up with an outcome. I was called by Eau
Claire law enforcement after the client sent a text message to her brother that said she planned to overdose on
medication to end her life today. When the police got there, the client was emotional, but cooperative and oriented. She
was willing to talk to me and doesn't seem to be under the influence of any substances. She said she has no history and
didn't plan to act on her thoughts.
The client said she wanted to stay home and doesn't want hospitalization. I'd be comfortable with her staying home if
she had someone stay with her; the problem is that her parents live in another state and her brother doesn't feel
comfortable staying with her tonight because of the message she sent and because he isn't sure if he's familiar enough
with her apartment to secure all of her potential hazards. I don't know if I feel okay with her staying home alone even
though she said she feels safe and isn't having thoughts of suicide anymore. The officer said he thinks she should at
least go to an emergency room to be evaluated for hospitalization, but I'm not sure it's needed. I'm thinking of maybe
sending a mobile worker to meet with everyone because I don't think she can be home alone, but I also don't think she
needs to be hospitalized right away if she's identifying that she feels safe right now. Maybe they'll see something in
person that I'm not seeing over the phone.
Updated 5.2.16

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